Anaemia in the premature infant and red blood cell transfusion: new approaches to an age-old problem

Abstract

Red blood cell (RBC) transfusion is a common intervention in very preterm infants with variable utilisation between centres and individual clinicians. This variation likely reflects uncertainty about who, when and how much to transfuse. Most RBC transfusions are given in small volumes as “top-up” for anaemia or cumulative phlebotomy loss. Whilst the newly born infant may have a low haemoglobin (Hb) value, it is uncertain if this is of clinical or physiologic significance except at extreme values. Little attention has been given to the potentially favourable effect of RBC transfusion on oxygen kinetics, particularly in the interval after birth when the risk of hypoxic ischaemia is high. Later anaemia, at the time of likely Hb nadir, more typifies anaemia of prematurity. In this article, we will firstly review the conventional model of RBC transfusion based on haemoglobin [Hb] thresholds and secondly, we will propose an alternate, individualised, practice based on the oxygen physiology. This effectively reframes the potential role of RBC transfusion in the very preterm infant and demands a new generation of clinical trials.